SCS/SB 928 - This act modifies provisions of law relating to health insurer reimbursement practices. REIMBURSEMENT OF CLAIMS (Section 376.384)
The act prohibits carriers from reducing payments for evaluation and management services that are otherwise eligible for reimbursement when reported by the same provider on the same day as a procedure.
DIRECT PAYMENTS TO PROVIDERS (Section 376.427)
The act specifies that payment for all services shall be made directly to providers when the carrier has authorized the patient to seek such services from a provider outside the carrier's network.
CLAIM AMOUNT CALCULATIONS AND MEDIATION (Section 376.690)
This act specifies that health care professionals shall send any bill for charges incurred for unanticipated out-of-network care to the patient's health carrier, and the carrier shall pay the professional directly. The act specifies how the payments are to be calculated, including with regard to cost-sharing requirements such as copayments, coinsurance, deductibles, and out-of-pocket maximums.
The Director of the Department of Insurance, Financial Institutions, and Professional Registration shall ensure access to a mediation process when a health care professional objects to the payments described in the act. The Department shall determine usual and customary rates for payments for health care services based on benchmarks from independent nonprofit organizations that are not affiliated with insurance carriers or provider organizations. The act specifies that health care professionals may initiate mediation if they believe the payment received for unanticipated out-of-network care does not properly account for certain factors. Health care professionals may combine similar claims and claims presenting a common issue of fact to be resolved in a single mediation process.
EMERGENCY SERVICE BENEFIT DETERMINATIONS (Section 376.1367)
This act specifies that necessity of emergency services to screen and stabilize a patient shall be determined by the treating physician.
Before a health carrier retrospectively denies payment for an emergency service, a qualified physician shall review the enrollee's medical records regarding the emergency condition at issue. Carriers shall not deny payment based predominantly on current procedural terminology or International Classification of Diseases (ICD) codes.
The act increases, from 30 minutes to 60 minutes, the amount of time health carriers have to provide authorization decisions for immediate post evaluation or post stabilization services before the services are deemed approved. Emergency service benefit payments shall be paid directly to the health care provider by the health carrier, regardless of whether the provider participates in the carrier's network.
This act contains provisions similar to provisions in SS/SB 982 (2018), HCS/SB 575 (2018), SB 1057 (2018), HCS/HB 2225 (2018), and HB 2463 (2018).
ERIC VANDER WEERD